What Did Happen during the Device Closure of the Patent Foramen Ovale?

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193 Despite there are some debates with catheter closure of the

patent foramen ovale (PFO),¹⁾ it can be an option in reducing the risk of recurrent paradoxical embolism and incidence of migraines. Although it has been a safe and promising technique with a low incidence of periprocedural complication,²⁾ some of complications during the procedure can be fatal. We found a linear, highly mobile lesion attached to the PFO closure device during the procedure. What did happen during the procedure?

A 48-year-old woman visited the emergency room with an acute onset of dysarthria. She was diagnosed with a cerebral in- farction of the superior branch of the right middle cerebral ar- tery. The patient had a history of transient ischemic attack about 4 years ago. At the time, her transesophageal echocardiography revealed the presence of about a 1 mm sized PFO with a signif- icant right to left shunt through it after having the Valsalva ma- neuver performed. She discontinued her medication after one month and did not visit the out-patient clinic. Because of the recurrent embolic events, the attending neurologist and con- sultant cardiologist decided to occlude the PFO with the Am- platzer^® PFO occlude device (AGA medical Co., Minneapolis, MN, USA).

The intervention was performed under local anesthesia with fluoroscopic guidance. After a venous puncture of the right femoral vein, the PFO was crossed under fluoroscopic guidance in the anteroposterior view by a standard length normal 0.035- inch guidewire. Initially, a J-tip was used to ensure passage through the hole. The interventionist tried to insert a 23-mm device through the J-tip. However, the procedure was not smooth and repeated attempts were performed. The device was finally inserted after several attempts. The follow-up echocardiography showed a freely moving linear mass lesion on the

tip of the left atrial disc. The transesophageal echocardiography demonstrated about a 13 cm sized linear mass attached to the tip of the left atrial disk (Fig. 1, Supplementary movie 1).

The highly mobile mass moved to-and-fro through the mitral valve. To reduce further catastrophic embolic events, the patient underwent open heart surgery to remove the device with the mass and occlude the PFO. We found with about a 20 cm sized linear fresh thrombus attached to the tip of the left atrial disc (Fig. 2). Fortunately, she was discharged without further complications after the surgery. Meticulous handling is necessary to prevent this injurious complication during procedure.

Supplementary movie legend

Movie 1. The transesophageal echocardiography shows about a 13 cm sized linear mass lesion attached to the tip of left IMAGES IN CARDIOVASCULAR ULTRASOUND J Cardiovasc Ultrasound 2015;23(3):193-194

• Received: March 1, 2015 • Revised: March 23, 2015 • Accepted: July 22, 2015

• Address for Correspondence: Jae-Hyeong Park, Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, School of Medicine, Chungnam National University, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea

Tel: +82-42-280-8237, Fax: +82-42-280-8238, E-mail: [email protected]

• This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

What Did Happen during the Device

Closure of the Patent Foramen Ovale?

Si Wan Choi, MD¹, Jae-Hyeong Park, MD¹, Jei Kim, MD², and Myung Hun Na, MD³

1Division of Cardiology, Department of Internal Medicine, Departments of ²Neurology, ³Cardiovascular Surgery, Chungnam National University Hospital, School of Medicine, Chungnam National University, Daejeon, Korea

KEY WORDS: Patent foramen ovale · Device closure · Thrombus · Complication.

Fig. 1. Transesophageal echocardiographic examination shows about a 13 cm sized linear mass (arrowheads) attached on the tip of the Amplatzer^® PFO occlude device (arrow).

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atrial disc and moves to-and-fro through the mitral valve.

References

1. Wolfrum M, Froehlich GM, Knapp G, Casaubon LK, DiNicolan- tonio JJ, Lansky AJ, Meier P. Stroke prevention by percutaneous closure of patent foramen ovale: a systematic review and meta-analysis. Heart 2014;

100:389-95.

2. Bruch L, Parsi A, Grad MO, Rux S, Burmeister T, Krebs H, Kleber FX. Transcatheter closure of interatrial communications for secondary preven- tion of paradoxical embolism: single-center experience. Circulation 2002;105:

2845-8.

Fig. 2. After the open heart surgery, about 20 cm sized fresh thrombus (arrowheads) is attached on the removed device (arrow).